Birth Plan? What Plan?
This is a draft of the article I have written for Empowering Birth eMagazine
The phrase Birth Plan always raises such opposite points of view. As a young midwife “in the system” I remember that the general consensus among the midwives and doctors was that the women who wrote a birth plan had the worst obstetric outcomes and they were “setting themselves up to be disappointed”. The most often given advice was to “be flexible”. However, I have always liked birth plans, so I was really pleased to have come across this recent bit of research (1).
The study split women in to three groups: ‘Self-determiners’, ‘Take it as it comes’ and ‘Fearful’, and looked at their mode and outcome of birth. It was no surprise to me that the “Fearful” group were more likely to report a negative birth experience, and the “Self Determiners” had the lowest risk of intervention. But I was interested to see that the “Take it as it comes’ cluster to have similar poor outcomes to the “fearful” group. The author went on to comment that this group of women warranted further attention from clinicians as they were the most likely to have seemed to have no issues antenatally. The study suggested that these women could benefit from clear information regarding the potential impacts of intervention on them and their baby and should be encouraged to take a more proactive approach to giving birth and therefore be “potentially positioned to avoid unnecessary intervention”(1).
This research backed up my belief that if you have a clear idea of what you want your birth to look like and take steps to ensure you get that birth, you are far more likely to have a better birthing experience. And that woman who just “be flexible” actually end up just doing what they are told.
But rather than quote more research on why I and other childbirth educators would all be on the side of making a birth plan, I thought it would be much more meaningful to find out what real women’s experiences of birth plans were. So I asked a group on Facebook if they had used Birth Plans and how they felt about them now. I was really pleased with the response and discussion this question generated and I was able to identify some key issues around birth plans
Here are some comments :
“Throw them out the window as soon as you go into labour? Neither of my 2 went to plan.”
“My plan was for a healthy baby.”
“I think that it is wise to know your options, then take it as it comes. Babies and births don’t follow your plan, they make their own!!”
“I think they are good. I think it makes you look at all your options and gives you the opportunity to make better, informed decisions. I just thought when I was pregnant with my first that you give birth lying flat on the bed and you have whatever drugs they throw at you. After my husband and I read into it, I was better informed and decided I wanted a natural drug free birth because of all the risks involved to myself and my baby. But I did know that could change depending. They didn’t exactly work as planned, as both were induced, but I ended up having 2 drug free births, 1st – 9lbs 13oz 8hrs and 2nd – 10lbs 2oz 8hrs again.”
“I think some kind of plan is helpful, I was separated from bub after birth as I needed surgery. He was cold, even when wrapped up, until we could be skin to skin. In hindsight I would have put on the plan for my other half to have bub on his chest if we were to be separated. Few little things like that.”
“So many people spend more time planning their weddings (wedding venue, what options are available at that venue, who they want there, options on vows, what dresses to wear, who they want to officiate etc) than they do their birth options”
On reflection I think one of the main issues is what the words “Birth Plan” mean to people, what are the images they conjure up for people.
As one woman commented:
“I think ‘birth plan’ means different things to different people. Some assume its water birth, candles, massage oil, perfection or else. That’s what we (birthing women) get ridiculed for. That if our plan doesn’t go to plan and we’re upset then we were stupid for having expectations. Most birth plans I’ve seen are more complex than that… If this happens I would prefer this. Women understand that birth isn’t always perfect, but that’s no reason for us to be mistreated, scorned, ridiculed, abused and threatened. Yes these things happen; I’ve heard countless examples and experience a few of them myself. “
Birth Plans have been viewed as “alternative” and unrealistic by hospital staff and I have seen doctors, and some midwives, roll their eyes when presented with them.
“Was it the glitter pen, swirly writing or pink paper that tipped them off that I had read too much and didn’t really understand the gravity of the situation I wonder?”
So it is important to take your birth preferences seriously. If you have done your research and write a comprehensive, well thought out plan you will be committed to that plan and far more likely to demand others respect it too.
Another important issue that came through was expectations. A few women commented on not getting the “perfect” birth they visualised when they wrote their birth plan.
“I don’t think it matters how much you plan for the perfect birth it never happens, listen to your body and let it work for you, don’t fight it and it will turn out the best it can, minimise your drugs that you take and go with the flow J”
“I did. It helped me get my head straight and set things in motion for a smooth birth experience. Having the best and worst case scenarios thought through allowed me to be calm and let things happen – looking forward to doing it all again one day:)”
I actually think it is really good to want the most wonderful experience you can have and write this down. After all, asking for what you want and focusing on the positive is a very powerful thing. But sometimes things do veer from the perfect and it is important to be prepared for this beforehand. So once you have written down your vision of your ideal birth, it is then important to consider all the “what if” scenarios and how you would like them to pan out. There are many things you can still include if your situation changes from music and candles (you can take LED candles into settings that can’t have a naked flame), to your preferences around being monitored. You can stay focused on still having the best possible outcome for you in any situation.
“Gives me the s***s when women are told not to have any good expectations. Obviously we all want a healthy baby at the end, but that doesn’t have to be at the expense of your own bodily autonomy and dignity.”
Reading through all the comments has also made me realised how important different personalities are when it comes to discussing birth plans.
“I had one as I am a control freak and it made me feel better, but once labour started, I realised I would throw it out the window if intervention was required. Thankfully my births were beautiful and peaceful and what we had hoped for.”
“I believe in educating yourself about birth options and the like however I feel birth plans set us up for grief if things don’t go to plan, while my labour and birth of my son was a beautiful experience it was not how I planned it and I suffered some grief afterwards and lots if regrets, if I hadn’t have had a plan then I wouldn’t have gone through these feelings I think, and I wouldn’t have had the regrets.”
“I had a birth plan for both labours. 1st plan was very basic and I was naive. 2nd one was more of a guide than a set in concrete plan, and I am so glad that I had it there.”
Some people really need a ‘plan’ while others will think of it more as their birth preferences. Some people need to tick of every one of their items in order to feel they achieved their ideal birth; others will be happy getting most of their wishes met. Which one are you? How will you feel if you write down your birth preferences and don’t stick to them? I think having preference for all situations will help, do you? Even the form of your birth plan depends on your personality. Some women like essays, some like list and other like posters. Which would work for you?
“Mine looked like this:
Plan to natural birth in pool at home.
IN THE EVENT OF TRANSFER:
I will request pain relief if I want it, please don’t repeatedly offer it.
I want to cord to be left alone to finish pulsing before it is severed.
Immediate skin on skin and feeding before weighing.
I want a natural third stage unless there is a reason for it to be augmented (ie: heavy bleed).
I wish to take placenta home.
IN THE EVENT OF CS:
I request that cord not be cut until it has finished pulsing.
Skin on skin with dad if mum unavailable.
Dad to always stay with baby if s/he is to be separated from mum.
I plan on breastfeeding, so no formula without my consent.”
Also this comment below made me realise that some people don’t like making decisions and if this is you and you will be truly happy with just leaving everything up to your care provider then that is your decisions to make too.
“There are plenty of people that find great relief in handing over their autonomy in these situations. That they don’t have to think about it and want heaps of guidance. That there is great liberation in not having to make decisions and letting the trained professionals doing what they do. And that’s awesome. All the power to them.”
But if you do decide to write down your birth preferences, how do you know what to ask for? Particularly with your first birth.
“How can you plan your first without knowing what to expect? The more you have the easier the plan gets lol”
“Totally pointless for a first birth. You think you know what you want but you don’t know what is ahead of you; you think you do, but you don’t.”
“Most people don’t even know about any antenatal education apart from the hospital ones, the ones that show you how to navigate the hospital guidelines and be truly informed. The model of care right now just pushes everyone to go private/public hospital, only strange weird people have a home birth.”
Education is so important. Yes, you don’t know how your birth will turn out, but you can have a very good idea of what you want to happen.
You could just Google “Birth Plans”, but they are often templates for other countries or the information is out of date and you may not understand all the terms and implications. Good quality childbirth education will help you explore all your options in all the possible situations you might find yourself in.
“It’s not totally pointless at all for a first birth. I have many wonderful first time mums who have chosen to educate themselves about labour and birth and make up very comprehensive birth plans! Just because it’s your first time, it doesn’t mean you shouldn’t know about options for pain relief, birthing and labouring positions, delayed cord clamping, skin to skin etc. If it’s your first time then this is when you SHOULD try to empower yourself by being knowledgeable!”
Another issue that came through was that your childbirth setting played a big part in whether women thought formal birth plan/preferences was important.
“I didn’t have much of a birth plan because I was planning a home birth vbac and I had already discussed with my doula and midwife what I would like to happen if I needed to transfer. If I have a 3rd if I can’t get a midwife and have to go to hospital I will be making a detailed birth plan, a specific one and a dot point one, but I will be having a doula to ensure that if things don’t go to plan, then they won’t fall apart either, i.e. I know what options are available, what to do or not do.”
“Similar to Katie, no specific birth plan because I had discussed with my Independent Midwife, my Mum and husband exactly what my wishes were for my birth. And I 100% trusted in them to respect them (and I trusted my midwife that if she said transfer was necessary or something in my plan wasn’t possible then that really was the case). My only detailed plan was what I wanted in case of transfer (skin to skin with me or with my husband if not possible to stay with me, no visitors until I had met my baby, no formula to be given without my express consent, delayed cord clamping, physiological 3rd stage etc.).
If I have any more babies and I end up needing a hospital birth then will definitely have detailed and specific birth preferences written up. And will hopefully have an IM with me to help me make decisions that are right for my baby and me.”
“I sort of did, it was more a guide for other half. I ended up transferring from a home birth and wish I’d had more of a transfer plan. Having reviewed the notes from the ob and midwife I’m certain that a vacuum extraction was not necessary at that stage. Intervention may have been needed at some point, but the only reason at that stage was the time limit put on by the ob. Next time I would ensure that all options are explored and explained to me, unless it’s a dire time critical emergency.”
So it seems that women who have chosen midwifery-led births don’t feel the need for a formal birth plan. This makes sense as they have had plenty of time to discuss their options and let their midwife know their preferences. They have also built up a trusting relationship so they know their wishes will be respested.
However, when you have an obstetrician it can be hard to make your preferences know. This is partly due to the fact that they only see you for a brief time at your antenatal visits, but also because of the culture of not feeling an equal and being able to ask questions. A birth plan is a great way to research your options and then have a list of questions ready to ask your obstetrician at each visit. It shows them you are a thinking adult and want to be part of the decision making process.
A birth plan can also help when you get to hospital, or are transferred to a hospital, as you probably won’t have met your midwife. Also, because you might see several midwives, it is an easy way for them to share your birth preferences.
The last comment also raises the issues of partners. It is vital that they are involved in the process of writing up birth preferences. You need to know that you are on the same page as them when it comes to your image of birthing. Also they might be the one who has to keep insisting that you be allowed to stick with your birth preferences for as long as possible. This can be a double edged sword though as the below comment points out, so make sure you do discuss all the ‘what ifs’.
“I had a detailed birth plan stating my intentions and wishes, no induction, no epidural – and when it came down to it, the whole system was against me. Every aspect of my plan didn’t work out for a bunch of reasons. The worst part was when my lovely husband tried to act on my behalf and remind me that I didn’t want an epidural, and as I had been given an unwilling shot of pitocin so *needed* the pain relief, I almost screamed at him to shut the f up and get me pain relief.”
The next issue after deciding to make a birth plan is what to do with it?
“I had one, but had to work extremely hard to ensure it was respected. Not the nicest thing when you are in the throes of labour…”
“Oh my birth plan was wonderful. I had what I did want (in great detail), what I could possibly tolerate and what I definitely didn’t want. I handed it to the nurses when I was admitted with pre-eclampsia and they immediately filed it. Was it the glitter pen, swirly writing or pink paper that tipped them off that I had read too much and didn’t really understand the gravity of the situation I wonder? I ended up having the exact opposite of what I wanted simply because – as it was put to me at the time – it was my life or the baby’s but hopefully they could save both of us. Oh well. No need to do another plan as we aren’t having anymore kids – I borrow them now.”
“I had a plan to the extent I knew what I did and didn’t want! But it all flew out the window when it all got complicated. At least next time I’ll be more confident in making sure I get what I wanted. I didn’t want an epidural- they told me I needed one. I didn’t want the cord clamped until it had stopped pulsing- they told me they couldn’t do that because of something (can’t remember what) I didn’t want her to be given the vit k – they told me she needed it because of her forceps delivery. I wanted skin on skin straight away- she wasn’t breathing properly so they took her away…I could go on all night. Needless to say next time I will demanding the things I wanted first time round. I’m still thankful I have my beautiful healthy little girl but I’m sad her birth wasn’t the magical experience I wanted! So yes I think a birth plan is important but so is the midwife/doctor understanding it!”
The message here is that you need to let your care givers know you have written down your birth preferences and the sooner the better. It is a great way of knowing if their idea of a good birth matches yours. If you find this out early enough there is always the option to change care givers. If you find this out at your birth, it can be really hard going for you and your partner.
I love the idea of turning your birth preferences into a poster and putting it up at the head of your bed. It is really hard to “file” a poster and also it is a constant reminder to everyone that you are an active participant in your labour. It is also a visual aid for yourself and your partner to stay with you birth preferences, plus if it is at the head of the bed you won’t be able to see it lying on your back. Finally, it will instantly transform the room into your birthing space.
However, if you are not a poster type of person what will you do to make sure your birth plan is seen and respected. Again, write it early so that you can take it with you to your antenatal appointments. Show it often and have several copies. Even if it is not a poster you can still stick it up in the labour ward (take Blu Tac with you to the hospital so you don’t even have to ask permission).
Some women also get their care provider to sign that they have read and will respect their birth plan.
Finally, I feel the need to raise the issue of Birth Trauma as it came strongly through the discussion and really is the heart of why I, and my like minded colleagues, recommend birth plans. Birth trauma, and PTDS, is being experienced but more and more women, and as women caring for birthing women and their partners we have seen the effects first hand. We know that it is the “Self- determiners”, the women who have a clear idea of how they want their birth to be and then implement ways of making it happen; the ones who stay involved in their birth, feeling they have control and are involved in the decision making process, who report the best birthing experiences regardless of the mode of birth. I won’t rely on more research but rather let you read the comments below. I would like to thank all the women for sharing their stories so openly and honestly.
“I had no birth plan with my first and was forced into things that I didn’t know better about and myself and child almost died. I had birth plan and education for my second and third. It was not cement, it could change but my birth was between me and my body I trusted myself and my body…I don’t always trust doctors to do what’s best. That’s me “
“Having had experienced birth trauma I just think not only having a birth plan but being educated is extremely important. Things can go wrong, things can be done to you and/or your baby that traumatise you… if you know what you expressly don’t want that can help you a lot. I’m not talking music or even pain medication. I’m talking unnecessary intervention that could severely impair you or your child. I wish I had my birth plan with my first saying no drugs like I did with my others. The pethidine they gave me minutes before my child was born stopped her breathing n she had to be resuscitated and suffered fits for months after, and the morphine in my epidural for my emergency c section that I was allergic too? Having a newborn baby n suffering from a severe allergic reaction is no fun.”
I will definitely have a list of birth preferences for my next birth, but will also have a doula or birth advocate as well as my partner. Yes you can’t plan for everything, but I refuse to hand over all my bodily autonomy to other people. They may be doctors or midwives or whatever, but they are still human and aren’t necessarily right all the time, and they also potentially say stuff to cover their butts. So when something is suggested I will ask fully for the reasons why (not just a glib ‘because I think it’s a good idea, we need to get your baby out, blah blah’) the alternative options, and what happens if we do nothing? I hate the attitude from some professionals that women, especially women in labour, are too stupid to understand detail. Yes you’re in a stressful situation, but it doesn’t take your brain away and I refuse to believe the ‘leave your dignity at the door’ thing is necessary.
Also we need to be gentle on ourselves. I hate that I didn’t stand up for myself more during the birth of my son, but recognise that it was bloody hard and how difficult it is to challenge the status quo! I don’t really blame myself as such, but I’ve learnt from it and will plan more for the different possibilities next time. Birth expectations and realities are such a complex thing, influenced by personal experience, knowledge, politics and trends. I’ve heard a few births over the phone (at work) and someone who is expecting to be at hospital with drugs and drs can be totally traumatised by a fast easy birth at home. Personally I’m ordering an easy birth at home for my next.”
“Google “birth trauma”. It is very real and can be the cause of many terrible things long after a birth, post natal depression, lack of bonding with baby, even PTSD. Women who feel that “things didn’t go how I would have liked” can suffer immensely. Yes we all want our babies to be born safe and alive, but how they get here and a woman’s beginning journey into motherhood – is profoundly important to many, many women.
Equally, being violated, having your rights taken away, having procedures done to you or your baby that you are uncomfortable with, not being asked CONSENT before anything is done – contributes to birth trauma. Which is why being educated, making up a birth plan and knowing what your rights are, is EXTREMELY important and has nothing to do with stupid regrets!”
“ I left the hospital a broken woman, dazed at having to shuffle out of hospital recovering from unplanned surgery, thinking that it should be ok the baby is here and healthy what am I thinking like this, only to find out later down the track when I began to process everything that I was a product of the system, textbook rollercoaster to an unplanned caesarean. I know midwives know as soon as the patients get onto that rollercoaster that they know which ones are going to be the surgical cases. I would daresay they would know before labour even commences, (if it does commence).”
“ I’m so passionate because I have friends and sister-in-law cry at their experience.”
“ But when it’s not a choice. When it’s forced, or not discussed and not consented (like my friend who thought they were just giving her fluids, but they induced her WITHOUT CONSENT in a popular Perth private hospital) THAT’S when there’s a problem.”
“Just a point to make – husbands/partners can be equally traumatised by births that go pear shaped. It is important for them to seek help also. My first birth was hideous (through NO fault of the Midwives or Doctors) and my husband was severely traumatised for a long time afterwards. Thankfully my second birth was beautiful and it showed him how labour and birth should be!”
“ I totally agree! It took both my partner and I a long time to stop crying about our daughter’s birth and it still makes me incredible sad when I do think about it, even teary! It wasn’t simply that I didn’t get the water birth I wanted or the music or whatever! Things were done to me that I didn’t want! Nobody listen to me, the midwife was horrible and treated me like a little girl who had no idea! (I’m not for the record lol) the anaesthetist said to me “your having an epidural because you’ve requested it” my partner told him ” no she hasn’t asked for it and no she doesn’t want it” I was so glad he was there for me but it all became very stressful quickly and he became scared for both me and the baby! They were telling me not to push and I needed to push but they kept telling me if I push I would damage my uterus and have to have a caesarean! Putting the fear of god in me! When they put the catheter in after the epidural they realised I was fully dilated and they could see her head so I could have been pushing like my body was telling me too! Needless to say they ended up cutting me to get the forceps in to pull her out as I couldn’t push her out! When we have another baby I want a home birth so I don’t have to listen to people getting it wrong and telling me to ignore my body but DP is scared after how Matilda’s birth ended up panning out.”
- Haines HM, Rubertsson C, Pallant JF et al (2012). The influence of women’s fear, attitudes and beliefs of childbirth on mode and experience of birth. BMC Pregnancy and Childbirth 12(55). http://tinyurl.com/bt6hx9y
Pip Wynn Owen is a childbirth educator, midwife and mother of 4. After being “thrown in” to teaching antenatal classes in a private hospital she decided she needed to do formal childbirth educator training with Birth International. This dramatically changed her style of teaching and approach to prenatal education. However after the birth of her 4th child, her first with an obstetrician in the private hospital system, she realised there was a real need to step outside the system and give women a truly independent childbirth education service.
She started ‘Birth Savvy…Ask for what you want’ in early 2012 and now runs Better Birthing Half Day Seminars and 2 Day Workshops, plus private childbirth education sessions in Perth WA. Birth Savvy’s focus is on helping women and their partners get the birthing experience they deserve through increasing their knowledge and confidence, and therefore their ability to have an equal relationship with their obstetricians.
She is fast becoming the voice for pushing for better births in Perth’s private hospitals with journalists seeking her opinions for newspapers, magazines and radio.
Pip also writes a blog on her website www.birthsavvy.com.au.